Impact of Health System Inputs on Health Outcome: A Multilevel Longitudinal Analysis of Botswana National Antiretroviral Program (2002-2013)

Practice environment determinants of job satisfaction among midwives at healthcare facilities in Accra Metropolis: A multicentre study

INTRODUCTION

Sustainable Development Goal 3 (SDG 3) has been one of the key goals for all partners of health globally. The health workforce especially midwives are among the principal skilled experts for achieving the goal. This is evidenced in the role they play in caring for pregnant women from the antenatal stages to the postpartum periods. However, very little has been reported about midwives' job satisfaction in Ghana. The study assessed the practice environment determinants of job satisfaction among registered midwives in Ghana.

MATERIALS AND METHODS

A cross-sectional design was adopted to recruit midwives from public and quasi-government hospitals in Accra Metropolis. Validated scales-'Measure of Job Satisfaction' and 'Practice Environment Scale of Nursing Work Index' were used for data collection. Data was analysed through descriptive statistics, Pearson correlation and linear regression.

RESULTS

Midwives had a positive perception of their work environment. They were generally satisfied with their job but were dissatisfied with their salaries. Key determinants of midwives' job satisfaction included years of work as a midwife, managers' leadership and support, and adequacy of human and material resources.

CONCLUSION

Improving midwives' job satisfaction through enabling the work environment will go a long way to improve healthcare provision in the healthcare delivery points in helping achieve SDG 3.

Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.

A Non-Linear Biostatistical Graphical Modeling of Preventive Actions and Healthcare Factors in Controlling COVID-19 Pandemic

BACKGROUND

With the insurgence of the COVID-19 pandemic, many people died in the past several months, and the situation is ongoing with increasing health, social, and economic panic and vulnerability. As most of the countries relying on different preventive actions to control the outcomes of COVID-19, it is necessary to boost the knowledge about the effectiveness of such actions so that the policymakers take their country-based appropriate actions. This study generates evidence of taking the most impactful actions to combat COVID-19.

OBJECTIVE

In order to generate community-based scientific evidence, this study analyzed the outcome of COVID-19 in response to different control measures, healthcare facilities, life expectancy, and prevalent diseases.

METHODS

It used more than a hundred countries' data collected from different databases. We performed a comparative graphical analysis with non-linear correlation estimation using R.

RESULTS

The reduction of COVID-19 cases is strongly correlated with the earliness of preventive initiation. The apathy of taking nationwide immediate precaution measures has been identified as one of the critical reasons to make the circumstances worse. There is significant non-linear relationship between COVID-19 case fatality and number of physicians (NCC = 0.22; p-value ≤ 0.001), nurses and midwives (NCC = 0.17; p-value ≤ 0.001), hospital beds (NCC = 0.20; p-value ≤ 0.001), life expectancy of both sexes (NCC = 0.22; p-value ≤ 0.001), life expectancy of female (NCC = 0.27; p-value ≤ 0.001), and life expectancy of male (NCC = 0.19; p-value ≤ 0.001). COVID-19 deaths were found to be reduced with increased medical personnel and hospital beds. Interestingly, no association between the comorbidities and severity of COVID-19 was found excluding asthma, cancer, Alzheimer's, and smoking.

CONCLUSIONS

Enhancing healthcare facilities and early imposing the control measures could be valuable to prevent the COVID-19 pandemic. No association between COVID-19 and other comorbidities warranted further investigation at the pathobiological level.

Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries

INTRODUCTION

Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed.

METHODS

PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed.

RESULTS

Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting.

CONCLUSION

There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.

Desirability Optimization Models to Create the Global Healthcare Competitiveness Index

The aim of this research is to enhance desirability optimization models to create a global healthcare competitiveness index (GHCI) covering 53 countries with gross domestic product per capita (GDP PC) of over $10,000. The GHCI is defined as an index that reveals the progress and quality of the healthcare systems in countries providing their patients with easier access opportunities to healthcare services within the scope of this work. Methods of statistical analysis have been adopted together with optimization models and techniques in this research. The optimum and feasible values of the factors considered influential on objective functions have been determined as the basis of healthcare expenditure (HE) and GHCI in those relevant countries. Those released optimum outcomes are displayed between 0.64 and 0.66 in terms of desirability value. The GHCI values of those aforementioned countries range from 0 to 6. The computed average of the GHCI values of those countries is estimated as 2.4758. Finally, GHCI values of 53 countries have been calculated to set the current basis of desirability optimization models. These findings will be deemed as the basic essence of those prospective theories to be established for the future researches to constitute a new index to measure the competitiveness of healthcare systems in various countries all over the world.

Healthcare system inputs and patient-reported outcomes: a study in adults with congenital heart defect from 15 countries

BACKGROUND

The relationship between healthcare system inputs (e.g., human resources and infrastructure) and mortality has been extensively studied. However, the association between healthcare system inputs and patient-reported outcomes remains unclear. Hence, we explored the predictive value of human resources and infrastructures of the countries' healthcare system on patient-reported outcomes in adults with congenital heart disease.

METHODS

This cross-sectional study included 3588 patients with congenital heart disease (median age = 31y; IQR = 16.0; 52% women; 26% simple, 49% moderate, and 25% complex defects) from 15 countries. The following patient-reported outcomes were measured: perceived physical and mental health, psychological distress, health behaviors, and quality of life. The assessed inputs of the healthcare system were: (i) human resources (i.e., density of physicians and nurses, both per 1000 people) and (ii) infrastructure (i.e., density of hospital beds per 10,000 people). Univariable, multivariable, and sensitivity analyses using general linear mixed models were conducted, adjusting for patient-specific variables and unmeasured country differences.

RESULTS

Sensitivity analyses showed that higher density of physicians was significantly associated with better self-reported physical and mental health, less psychological distress, and better quality of life. A greater number of nurses was significantly associated with better self-reported physical health, less psychological distress, and less risky health behavior. No associations between a higher density of hospital beds and patient-reported outcomes were observed.

CONCLUSIONS

This explorative study suggests that density of human resources for health, measured on country level, are associated with patient-reported outcomes in adults with congenital heart disease. More research needs to be conducted before firm conclusions about the relationships observed can be drawn.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02150603. Registered 30 May 2014.

Urgently Creating the Better in Global Health

In this issue of the Hastings Center Report, Govind Persad and Ezekiel Emanuel argue that "[t]he provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the worst off." I agree that we should not let the perfect get in the way of the good, but just providing cheaper, less effective treatment for utilitarian or other reasons is not a comprehensive approach to global health. In my experience as an on-the-ground global health practitioner, the choice is never that simple. As time passes, dynamics evolve, and so should the responses to a global health problem. The goal of global health should be urgently improving responses toward better access to care and equity in health, without which the good may become the enemy of the better. In other words, there are places and times in which the approach Persad and Emanuel describe may be appropriate, but their recommendations fail to account for the realities of a population-level medical emergency and for the fact that once an emergency is initially or partially addressed in any setting, time can be the enemy, if it breeds complacency.

Building Health System Capacity through Medical Education: A Targeted Needs Assessment to Guide Development of a Structured Internal Medicine Curriculum for Medical Interns in Botswana

Background:

Medical internship is the final year of training before independent practice for most doctors in Botswana. Internship training in Botswana faces challenges including variability in participants’ level of knowledge and skill related to their completion of medical school in a variety of settings (both foreign and domestic), lack of planned curricular content, and limited time for structured educational activities. Data on trainees’ opinions regarding the content and delivery of graduate medical education in settings like Botswana are limited, which makes it difficult to revise programs in a learner-centered way.

Objective:

To understand the perceptions and experiences of a group of medical interns in Botswana, in order to inform a large curriculum initiative.

Methods:

We conducted a targeted needs assessment using structured interviews at one district hospital. The interview script included demographic, quantitative, and free- response questions. Fourteen interns were asked their opinions about the content and format of structured educational activities, and provided feedback on the preferred characteristics of a new curriculum. Descriptive statistics were calculated.

Findings:

In the current curriculum, training workshops were the highest-scored teaching format, although most interns preferred lectures overall. Specialists were rated as the most useful teachers, and other interns and medical officers were rated as average. Interns felt they had adequate exposure to content such as HIV and tuberculosis, but inadequate exposure to areas including medical emergencies, non-communicable diseases, pain management, procedural skills, X-ray and EKG interpretation, disclosing medical information, and identifying career goals. For the new curriculum, interns preferred a structured case discussion format, and a focus on clinical reasoning and procedural skills.

Conclusions:

This needs assessment identified several foci for development, including a shift toward interactive sessions focused on skill development, the need to empower interns and medical officers to improve teaching skills, and the value of shifting curricular content to mirror the epidemiologic transition occurring in Botswana. Interns’ input is being used to initiate a large curriculum intervention that will be piloted and scaled nationally over the next several years. Our results underscore the value of seeking the opinion of trainees, both to aid educators in building programs that serve them and in empowering them to direct their education toward their needs and goals.

Strengthening medical training programmes by focusing on professional transitions: a national bridging programme to prepare medical school graduates for their role as medical interns in Botswana

BACKGROUND

The improvement of existing medical training programmes in resource-constrained settings is seen as key to addressing the challenge of retaining medical graduates trained at considerable cost both in-country and abroad. In Botswana, the establishment of the national Medical Internship Training Programme (MIT) in 2014 was a first step in efforts to promote retention through the expansion and standardization of internship training, but MIT faces a major challenge related to variability between incoming trainees due to factors such as their completion of undergraduate medical training in different settings. To address this challenge, in August 2016 we piloted a bridging programme for foreign and locally trained medical graduates that aimed to facilitate their transition into internship training. This study aimed to describe the programme and evaluate its impact on the participants' self-rated perceptions of their knowledge, experience, clinical skills, and familiarity with Botswana's healthcare system.

METHODS

We conducted a national, intensive, two-week programme designed to facilitate the transition from medical student to intern and to prepare all incoming interns for their work in Botswana's health system. Participants included all interns entering in August 2016. Formats included lectures, workshops, simulations, discussions, and reflection-oriented activities. The Kellogg Foundation Outcomes Logic Model was used to evaluate the programme, and participants self-rated their knowledge, skills, and attitudes across each of the programme objectives on paired questionnaires before and after participation.

RESULTS

48/54 participants (89%) provided paired data. Participants reported a high degree of satisfaction with the programme (mean 4.2/5). Self-rated preparedness improved after participation (mean 3.2 versus 3.7, p < 0.001), as did confidence across 18/19 knowledge/skill domains, suggesting that participants felt that the programme prepared them for their internship training. Exploratory analysis revealed that 20/25 participants (80%) reporting either no effect or a negative effect following participation had rated themselves "extremely" or "quite" prepared beforehand, suggesting the programme grounded expectations for interns who initially were overconfident. In contrast, no interns who had initially rated themselves "moderately" or "somewhat" prepared reported a decline in their self-rated sense of preparedness. Interns commented on the benefits of learning about roles/responsibilities, interacting with clinicians from Botswana's healthcare sectors, and the sense of community the programme engendered.

CONCLUSIONS

This programme was feasible to implement and was well-received by participants. Overall, participants perceived an enhancement of their knowledge, skills, and expectations about their role in Botswana's health system after completion of the programme. Our results are likely to be of interest to educators dedicated to training, professional transitions, and career pathways in similar settings in the region and beyond.